Mr. Ying is scheduled for surgery. He says to the nurse, “I am so frightened-what if I don’t wake up?” What would be the best response?

“You have a wonderful doctor.”

“Let’s talk about how you are feeling.”

“Everyone wakes up from surgery!”

“Don’t worry, you will be just fine.”

Answer and Explanation

The Correct Answer is B

Preoperative anxiety is common; patients need empathy and a safe space to express fears. The nurse’s best immediate response acknowledges the feeling and opens a conversation so underlying concerns (fear of death, anesthesia, pain, loss of control) can be explored, corrected, and managed. Therapeutic communication (open-ended invitation, active listening) improves trust.

Rationale for correct answer:

2. “Let’s talk about how you are feeling.” Invites the patient to express concerns, shows empathy, and lets the nurse assess the intensity and content of the fear.

Rationale for incorrect answers:

1. “You have a wonderful doctor.” Diverts attention from the patient’s feelings and gives a vague reassurance rather than exploring fear.

3. “Everyone wakes up from surgery!” False reassurance; minimizes the patient’s worry and may undermine trust.

4. “Don’t worry, you will be just fine.” Dismissive; it shuts down emotional expression instead of addressing it.

Take home points:

Use open-ended, empathetic statements that invite expression rather than offering premature reassurance.
Exploring fears lets you assess need for teaching, more explanation from anesthesia, or anxiolytic interventions-don’t dismiss or minimize.

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Correct Answer is ["A","C"]

Explanation

When advancing a postoperative patient from NPO to clear liquids, the nurse checks for signs the GI tract and protective reflexes have returned: no nausea/vomiting, presence of bowel sounds or passage of flatus, intact gag reflex, and stable vital signs.

Rationale for correct answer:

1. Does not complain of nausea or vomiting: Absence of nausea or vomiting reduces aspiration risk and indicates the patient is more likely to tolerate oral intake.

3. States passing flatus: Passing flatus is an objective sign of returning bowel motility (ileus resolving) and supports advancing diet to clear liquids.

Rationale for incorrect answers:

2. Pain level is maintained at a rating of 2-3 out of 10: Good pain control is desirable, but a moderate pain score alone doesn’t guarantee GI tract readiness or safe swallowing.

4. Ambulates with minimal assistance: Ambulation shows overall stability and helps GI motility, but it is not by itself a direct indicator that the GI tract can tolerate oral intake.

5. Expresses feeling “hungry”: Subjective and not sufficient. Hunger does not confirm bowel function or absence of aspiration risk and should not be the sole reason to advance diet.

Take home points:

Advance to clear liquids when objective signs of GI function and tolerance are present.
Subjective cues (feeling hungry) and general stability (ambulating) are helpful context but do not replace primary clinical indicators of GI readiness.

A. Cough and deep breathe every 2 hours. B. Maintain NPO status for 48 hours. C. Encourage frequent ambulation. D. Take vital signs every 4 hours.

Correct Answer is C

Explanation

Postoperative gas pain commonly results from anesthetic effects, decreased bowel motility, swallowed air, and manipulation of the bowel. Promoting early and frequent ambulation, position changes, and encouraging passing flatus are the most effective nonpharmacologic measures.

Rationale for correct answer:

3. Encourage frequent ambulation: Ambulation stimulates intestinal motility and helps move trapped gas, reducing distention and discomfort. It’s a first-line, low-risk intervention.

Rationale for incorrect answers:

1. Cough and deep breathe every 2 hours: Coughing and deep breathing primarily prevent pulmonary complications (atelectasis) and do not directly relieve intestinal gas.

2. Maintain NPO status for 48 hours: Prolonged NPO is unnecessary for routine gas pain and may delay return of bowel function; early oral intake as tolerated and activity often help.

4. Take vital signs every 4 hours: Monitoring vitals is important for overall postop care but will not directly relieve gas pain.

Take home points:

Early ambulation is the single most effective nursing intervention to relieve postoperative gas pain by stimulating bowel motility.
Use multimodal measures - positioning, ambulation, analgesia to allow activity, and ordered medications such as simethicone.

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Mr. Ying is scheduled for surgery. He says to the nurse, “I am so frightened-what if I don’t wake up?” What would be the best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply

Correct Answer is ["A","C"]

Explanation

Gas pains are a common postoperative discomfort. Which of the following nursing actions implemented in the plan of care would be most likely to relieve gas pains?

Correct Answer is C

Explanation

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which two interventions are a priority? Select all that apply

An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? Select all that apply

Mr. Ying is scheduled for surgery. He says to the nurse, “I am so frightened-what if I don’t wake up?” What would be the best response?

Which of the following surgical patients is at a greater risk for alterations in body image?

The nurse plans to remove the client’s sutures. Which action demonstrates appropriate standards of care? Select all that apply

Mr. Moreno has had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system?

Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? Select all that apply